Exploring the association between early adaptive schemas and self‐reported eating disorder symptomatology

Abstract Objective The current study aimed to examine the relationship between early adaptive schemas and eating disorder symptomatology in adults. Method A cross‐sectional, correlational design was used to collect data from 352 females and 36 males aged between 18 and 49 years (M = 25.70, SD = 7.04). Participants completed an online questionnaire, which included The Young Positive Schema Questionnaire (YPSQ), Eating Disorder Examination‐Questionnaire (EDE‐Q) and demographic measures. Results Four separate hierarchical multiple regression analyses showed that high levels of Healthy Boundaries and low levels of Optimism significantly predicted lower Restraint, Eating Concern, Shape Concern and Weight Concern scores. Additionally, higher scores in Emotional Openness and Social Belonging significantly predicted lower Eating Concern, while higher scores in Self‐Care significantly predicted lower levels of Shape Concern. Conclusion The findings highlight the protective function that certain early adaptive schemas may play in mitigating eating disorder symptomatology. Moreover, the findings allude to potential modifiable therapy targets in the treatment of eating disorders. Further research is needed to investigate any differences in early adaptive schemas between eating disorder diagnoses.

weight and shape. Moreover, individuals with eating disorders tend to judge themselves almost exclusively in terms of their eating, shape or weight (Fairburn et al., 2003). Across diagnostic categories, presentations comprise either exclusively or a combination of caloric restriction (e.g., anorexia nervosa), binge eating (e.g., binge eating disorder) or purging behaviour (e.g., bulimia nervosa). Although, more than half of individuals receiving treatment fall within the diagnostic category of eating disorder not otherwise specified (OSFED), which manifests as characteristic symptoms that do not meet the criteria of a specific eating disorder diagnostic category (American Psychiatric Association, 2013).
The most widely researched and accepted theoretical framework for the treatment of eating disorders is cognitive behavioural therapy (CBT). Early models of CBT emphasized the roles in which disordered eating and maladaptive attitudes towards weight and shape contributed to the maintenance of eating disorder pathology (Fairburn, 1981). Building on this premise, Fairburn and colleagues (Fairburn et al., 2003) subsequently proposed a transdiagnostic model and 'enhanced' form of CBT (CBT-E), detailing four additional features of eating disorder maintenance: (1) low self-esteem, (2) perfectionism, (3) interpersonal difficulties and (4) mood intolerance.
The transdiagnostic model suggests that all eating disorder diagnoses display shared but distinctive, clinical features that tend to be maintained by similar psychopathological processes. A recent systematic review of 20 studies provided support for CBT-E as an effective treatment for adults with a range of eating disorder diagnoses (Atwood & Friedman, 2020). de Jong and colleagues, using a randomized controlled trial, also reported significant effectiveness in the use of CBT-E compared with usual treatment (de Jong et al., 2020).
Despite the noted efficacy of CBT and its proponents (i.e., CBT-E) for some eating disorder presentations such as bulimia nervosa and binge eating disorder, long-term treatment outcomes have remained inconsistent (e.g., Agras et al., 2000;Poulsen et al., 2014;Waller et al., 2014). Specifically, literature (i.e., Atwood & Friedman, 2020;de Jong et al., 2020) has noted that eating disorder psychopathology improved in the short term but was not maintained, compounded by significant participant attrition.
Several factors have been implicated in limited treatment outcomes for certain eating disorder populations such as entrenched cognitive schemata, problematic attachment styles and developmental trauma, treatment drop-out and complex comorbidities (e.g., personality disorders; Vall & Wade, 2015). Such findings suggest that the current CBT model is necessary but not sufficient to conceptualize eating disorders, and further research is required to clarify and extend existing conceptualizations, which may contribute to improved outcomes in the field (Klump et al., 2009).
Given the aforementioned complexities associated with treatment, schema theory (Young, 1990;Young et al., 2003) may provide a complementary framework for explaining the aetiological and maintaining factors associated with eating disorders. Schema therapy, originally developed to expand on traditional CBT, endeavours to address developmental processes that contribute to and maintain psychopathology such as temperament, attachment and adverse early childhood experiences (Young, 1990;Young et al., 2003). The overlap of schema therapy with eating disorder pathology derives from evidence that highlights that individuals with eating disorders endorse both disorder-specific cognitions and unconditional negative beliefs about the self, others and the world (Hughes et al., 2006). Such evidence aligns with Young and colleagues (Young et al., 2003) description of early maladaptive schemas, which are a central tenet of schema therapy. Defined as pervasive themes regarding the self, early maladaptive schemas are thought to develop in response to consistently unmet emotional needs during childhood and contribute to the aetiology and maintenance of psychopathology (Young et al., 2003).
There are currently 21 proposed early maladaptive schemas, with the inclusion of three recent additions (Arntz et al., 2021), which fall under five domains and are outlined in Table 1. Thus, the schema model, developed from a range of psychological theories, aims to treat early maladaptive schemas through the alteration of entrenched negative life patterns, that is, cognitive and behavioural changes (Young et al., 2003).
Over two decades of research has documented the relationship between early maladaptive schemas and eating disorder symptomatology. Studies using clinical samples have found that individuals, regardless of eating disorder diagnosis, consistently report significantly higher early maladaptive schema scores than their nonclinical counterparts (e.g., De Paoli et al., 2017;Jones et al., 2005;Legenbauer et al., 2018;Leung et al., 2000;Leung & Price, 2007;Maher et al., 2022;Sines et al., 2008). Moreover, positive associations between early maladaptive schemas and a range of eating disorder measures such as drive for thinness, body dissatisfaction, bulimic symptoms and binge eating have emerged in nonclinical samples (e.g., Hovrud et al., 2020). Building on this evidence, Waller and colleagues (Waller et al., 2007) (Waller et al., 2007). Taken together, the model indicates that while eating disorder diagnoses can be differentiated by behaviours and schema processes, schema content is transdiagnostically consistent across eating disorder symptomatology.
Since its conception, the schema model has been used to inform eating disorder treatment. Overall, modification of schema content using group programs has been successful in reducing the severity of schemas and eating disorder pathology (e.g., Mącik & Sas, 2015;Simpson et al., 2010). Such findings suggest that schema content is amenable to change in the therapeutic setting. However, given the complex and pervasive nature of eating disorder pathology, improvement of therapeutic outcomes remains an ongoing focus of research. Seligman, a proponent of positive psychology, proposed that increasing the focus on positive psychological outcomes and interventions may strengthen traditional interventions that tend to emphasize the reduction of psychopathology. In a 2005 article examining the progress of the field, Seligman et al. (2005) found moderate to large effect sizes for clinical interventions aiming to increase happiness. More importantly, a reduction in depressive symptoms was noted and happiness scores were maintained 6 months after the cessation of treatment, illustrating the possible effectiveness of positive psychology interventions. Recently, the field of positive clinical psychology looked at the unique contribution of positive psychological constructs in predicting mental health outcomes (Wood & Joseph, 2010). Moreover, the field has drawn attention to research that found that psychological interventions focussed on increasing positive psychological constructs have been as successful in reducing psychopathology as those that focus on reducing negative constructs (Geraghty et al., 2010). For example, a recent meta-analysis (Hendriks et al., 2020) and systematic review (Chakhssi et al., 2018) found that increasing positive emotions, cog-  Theoretical counterparts of early maladaptive schemas derived from Louis et al. (2018). Note that early adaptive schemas in bold were the final constructs, as outlined in Louis et al. (2018). schemas, with 14 theoretical counterparts to early maladaptive schemas, as outlined in Table 1. Named early adaptive schemas, they consist of positive functions and adaptive behavioural dispositions that emerge during childhood and adolescence when one's core emotional needs are adequately met (Young et al., 2003). Preliminary research found a significant negative relationship between early adaptive schema scores and depression, anxiety and stress (Louis et al., 2018). That is, individuals with positive core beliefs regarding themselves, others and the world were more likely to experience positive mental health outcomes. Within the eating disorder field, a dearth of research has examined the relationship between positive psychological constructs and eating disorder symptomatology. One study has examined the association between positive core beliefs and eating disorder symptoms in a nonclinical sample, which found that individuals who endorsed positive individual self-beliefs (e.g., I am a capable person; I am resilient; I am independent) were more likely to endorse lower levels of self-reported eating disorder symptoms (Cooper & Proudfoot, 2013).

| Design
The study was a correlational, cross-sectional online survey. Sixteen predictor variables and four outcome variables were included in the study. Predictor variables included age, BMI, and early adaptive schemas. Eating disorder symptomatology was the outcome variable.

| Demographic measures
Demographic information included sex, age, nationality, height, weight, education level and current mental disorder diagnosis.

| Early adaptive schemas
The Young Positive Schema Questionnaire (YPSQ; Louis et al., 2018) is a 56-item scale designed to measure positive thinking patterns and experiences (i.e., positive schemas) and includes 14 subscales. Items are rated on a 6-point Likert scale that ranges from a score of 1 (Completely untrue of me) to a score of 6 (Describes me perfectly).
Sample items include the following: "I like to do well but don't have to be the best" (Realistic Expectations) and "I trust that people won't leave me, do I don't act needy and drive them away" (Stable Attachment

| Procedure
After obtaining institutional ethical approval, participants were recruited via social networking websites with a link to the online survey. Volunteers followed the survey link and were informed of the study's purpose, risks and safeguards, along with information regarding consent, anonymous participation and access to information. The study was described as an exploration of the relationship between positive beliefs and eating-related thoughts and behaviours. After obtaining consent, participants were invited to complete demographic questions followed by psychometric measures. Contact details of suitable support services were provided within the survey. Following completion of the questionnaire, participants were given the opportunity to enter a monetary prize draw ($50 AUD Amazon voucher). To maintain confidentiality, prize draw was via an external survey link, and the winner was chosen randomly by an individual who was independent from the current study. 4 | RESULTS

| Preliminary analysis
An a priori power analysis was calculated using G*Power (Faul et al., 2007). The sample size for the current study (n = 388) was considered adequate given the analysis indicated that 143 would be the required sample to detect a medium effect size (ƒ 2 = 0.15) using standard alpha (α = .05), power of .80 and 16 predictor variables. Prior to conducting the primary analyses, data were screened for univariate and multivariate outliers and violations of normality. The assumptions of linearity, homoscedasticity, collinearity, independence of errors and multivariate normality were met.
Descriptive statistics and correlations between study variables are presented in Table 2. Mean early adaptive schema scores were slightly below normative values (Louis et al., 2018), whereas mean EDE-Q subscale scores were above normative values (Fairburn & Beglin, 1994). Participants with higher early adaptive schema scores were more likely to be older and report lower levels of eating disorder pathology. Correlations between early adaptive schema and EDE-Q subscale scores were strong and in the expected negative direction.

| Primary analyses
Four separate hierarchical multiple regression analyses were conducted to assess which, if any, early adaptive schemas predicted eating disorder symptomatology, as measured by the four EDE-Q subscales.

| Eating concern
In predicting Eating Concern, as shown in

| Shape concern
In predicting Shape Concern, as shown in

| Weight concern
In predicting Weight Concern, as shown in T A B L E 4 Hierarchical multiple regression analysis predicting eating concern from early adaptive schemas  Such findings suggest that both adaptive and maladaptive schemas can exist simultaneously and are not merely polar opposites of one another. This assertion was examined in a recent study, which found that all early adaptive schemas provided predictive utility of mental health outcomes above and beyond that of early maladaptive schemas (Louis et al., 2018). T A B L E 5 Hierarchical multiple regression analysis predicting shape concern from early adaptive schemas their parents to be less caring and overly controlling (Brown et al., 2016;Deas et al., 2011;Leung et al., 2000). Taken together, such findings suggest that individuals endorsing worse eating disorder symptomatology likely experienced less positive interactions with attachment figures, which hindered the development of unconditional positive core beliefs.
This notion is further reinforced by attachment theory, which suggests that repeated interactions with attachment figures lead to internal working models in children and become the basis of affect regulation and interpersonal behavioural styles in adult life (Bowlby, 1978). These findings align with the present study, which found that lower levels of Emotional Openness and Social Belonging predicted higher levels of Eating Concern. Indeed, the transdiagnostic model purports that poor affect regulation and interpersonal relationships, among other components, are key maintaining factors of eating disorder pathology (Fairburn et al., 2003). Research has shown that individuals who endorsed positive social beliefs (e.g., I fit into a group; I am a friendly person) reported fewer eating disorder symptoms (Cooper & Proudfoot, 2013). In contrast, clinical eating disorder samples have consistently reported significantly fewer social group memberships, higher levels of rejection sensitivity, increased social isolation, fear of being ostracized and worse interpersonal functioning than their nonclinical counterparts (e.g., Arcelus et al., 2011;De Paoli et al., 2017;Keith et al., 2009;Meneguzzo et al., 2020;Rowlands et al., 2021). Moreover, eating disorder symptomatology has been associated with poor distress tolerance, emotional instability and difficulty experiencing both pleasant and unpleasant emotions (e.g., Hambrook et al., 2011;Hovrud et al., 2020;Overton et al., 2005).
Building on this premise, Waller and colleagues proposed that eating disorder behaviours are used to avoid negative affect associated with schema activation and attachment related distress (Waller et al., 2007). Although the model focused heavily on schemas processes, the model's assertions align with research that shows that eating disorder samples display higher levels of avoidance coping (e.g., Vanzhula et al., 2020). Taken together, it appears that individuals who experience positive early childhood experiences may go on to develop healthy affect regulation and interpersonal skills, which reduces their need to use dysfunctional eating disorder behaviours to avoid distressing affect.
An alternative perspective suggests that metacognitive theory may help to explain the relationship between eating disorder symptomatology and core beliefs. In a recent literature review, Mansueto and colleagues sought to understand the development of T A B L E 6 Hierarchical multiple regression analysis predicting weight concern from early adaptive schemas Harm and Pessimism), which found that individuals with an eating disorder diagnosis reported significantly higher Pessimism and Vulnerability scores than their nonclinical counterparts (Elmquist et al., 2015).
That is, they were more likely to report higher levels of negativity, hopelessness and fear about their future. A possible explanation for the discrepancy in findings is that activation of certain early adaptive schemas, in combination with pre-existing early maladaptive schemas, may present as a specific overcompensatory eating disorder coping style that is conceptualized as excessive optimism. This coping style functions to maintain eating disorder symptomatology through denial of various aspects of the eating disorder and avoidance of emotional expression that may lead to rejection or criticism (Simpson & Smith, 2020). This assertion aligns with the present study, as lower levels of Emotional Openness were associated with higher levels of Eating Concern. The finding should also be interpreted with caution, given that Optimism only accounted for 1% of variance in eating disorder psychopathology.

| Limitations and future research
Several limitations need to be considered in the present study. First, the correlational study design indicates that causation and direction of relationships cannot be inferred. Although schema theory proposes that schemas are formed in early childhood and adolescence, it may be the case that the development of weight and shape-related beliefs occurred prior to the development of early adaptive schemas. This is especially relevant, given that children are being exposed to body-related attitudes via parents and media at younger ages (Daragnova, 2013 Finally, it should be highlighted that although a combined predictive variance of between 16% and 31% was observed for all subscales, each early adaptive schemas accounted for less than 2% of the variance in eating disorder symptomatology scores. Little is known about the nature of the relationship between positive psychological constructs and eating disorder outcomes. Despite a large body of schema therapy research validating the presence of early maladaptive schemas in individuals with eating disorders, the present findings concerning the predictive nature of specific early adaptive schemas on eating disorder outcomes remain putative due to the complexity of factors that contribute to eating disorder aetiology and maintenance. For example, while disrupted attachment relationships and unmet emotional needs have been consistently implicated in eating disorder pathology, research has identified factors such as genetics and trait perfectionism as potential covariates. Moreover, the present findings should not be exclusively interpreted in the context of schema therapy, especially given Louis et al. (2018) suggestions about the proposed mechanism of action for early adaptive schemas in predicting mental health outcomes. For example, the researchers suggest that while early adaptive schemas may be theoretical counterparts of their opposite early maladaptive schemas, they also propose the notion that early adaptive schemas may be unique constructs that develop in childhood and adolescence and cluster separately to early maladaptive schemas in the brain. Future research should focus on validating the YSPQ in clinical eating disorder samples. Given the observed differences in early maladaptive schema scores between eating disorder and dieting samples despite reported similarities in weight and shape concern (e.g., Cooper & Turner, 2000;Leung & Price, 2007), it is evident that schema content is unique in eating disorders. Therefore, future studies are required to clarify the nature of early adaptive schemas in eating disorder samples.

| CONCLUSION
The present study found that greater Healthy Boundaries were associated with lower levels of eating disorder psychopathology. In contrast, greater Optimism was associated with worse eating disorder psychopathology. Moreover, Emotional Openness and Social Belonging and Self-Care were important in predicting lower levels Eating Concern and Shape Concern, respectively. Given that this is the first study to demonstrate the relationship between early adaptive schemas and eating disorder cognitions and behaviours, this evidence, although putative, sets the stage for future research to identify causal effects of early adaptive schemas on eating disorder symptomatology.